Tuesday, June 27, 2017

As
a pediatrician, I work to keep children healthy so they can grow up and achieve
their dreams.Occasionally, my naïve
optimism has gotten the better of me.I especially
have a soft spot for angry, defiant children.These children are given my undivided attention and respect and I expect
the same in return. I never call them names, insult them, or label them.On the contrary, I have high expectations and
am always encouraging them to be their best selves.I often hug them tight as their anger gives
way to tears, reassuring them as much as possible.

A
decade ago, I took care of a blended family with three children by three different
fathers.The oldest boy, Bobby, was an
“angry” seven year old with wide eyes and an endearing, crooked smile.His mother was exasperated and demanded
tranquilizers be prescribed to him or she would switch physicians.I asked Bobby what was going on.He talked about conflicts with his mothers’
new boyfriend and how he resented this man calling him lazy and stupid. He had
tears in his eyes, which broke my heart.

I
talked to him about ways to deal with his anger and recommended a nearby family
counselor.I hugged him, acknowledged
his frustration, and told him he was neither lazy nor stupid.I reminded him to never give up on himself and
no matter what happened, I would always believe in him.Needless to say, his mom changed physicians
and I did not see Bobby again.

When
children enter the Juvenile Detention system, they lose Medicaid insurance
coverage.As a result, I was the consulting
physician at our local juvenile facility.I cared for children who were addicts, thieves, vandals, and committed a
variety of other crimes.I reviewed
their health history, updated immunizations, and prescribed medications when
necessary.It was difficult to reconcile
my job as a physician looking into their eyes and seeing their fear, yet
knowing I could do nothing to alleviate the obstacles they faced.

My
toughest day was the one when I unexpectedly ran into Bobby.I had been consulting over the phone with the
RN at Juvenile Hall on a teenager who sustained injuries during arrest by coordinating
care with a local specialist.Over the
five day time period, I never asked his name.

Each
week, I drove to Juvenile Hall to sign orders and examine children when
necessary.That day, I came upon Bobbys’
chart.“This is my injured boy? I know
him.” I declared.She smiled and
replied, “He said you were his doctor when he was little, and he is excited to
see you.”

As
the guard left to get Bobby, I told him, “Be prepared.I am going to hug this next one like he is my
own son.I do not care what he
did.”The guard gave me a funny look as
he sauntered away.I had thought of
Bobby so often over the years, yet had the sinking feeling things had been far
from rosy.As Bobby walked through the metal
double doors, I was struck by how much he had changed in both size and stature (now
well over 6 feet tall.) We hugged as if
no time had passed, “Bobby, you are so much more grown up than I remember.”He smiled with that same crooked grin I found
so endearing a decade before. “You are
so much tinier than I remember,” he replied looking down at me.

Over
the last decade, his mother and her children moved multiple times, had done their
fair share of couch surfing, and Bobby had been suspended for misbehavior and
truancy.A few months before his arrest,
his mother kicked him out, he moved back to the area, was stealing, using drugs,
and suspected his 17 year old girlfriend was newly pregnant.

Crestfallen,
I almost started crying, then and there.My dreams for this young boy from ten years ago were shattered into tiny
little pieces.In my mind, at the tender
age of seven, he had been a ball of clay ready to be molded into something
beautiful.Instead, all hope had been
extinguished from the young man who stood before me now.There was no sparkle in his eye; the devilish
grin was all that remained of that innocent child I once knew.

Honest
to a fault, we talked about lost opportunities and lasting consequences of his poor
decisions.I encouraged him to dream of a
future outside of prison walls.I
reminded him of how kind, warm, and genuine he was with a great deal to offer
the world.

Unprepared
for my own feelings of sadness and disappointment, this experience hit me unexpectedly
like a ton of bricks.I have yet to
recover the abiding faith that all children can achieve their dreams. It has been an extremely tough lesson to accept;
yet it reaffirmed my commitment to continue encouraging, loving, and supporting
each and every child who walks through my doors and into my heart.

While
I do not know where Bobby is today, I hope our brief encounter had as profound
an impact on him and he did on me.Kiddo,
I think of you every day and hope you are safe, know you are loved, and remember
you have much to offer the world.

Tuesday, June 20, 2017

As we move into the longer and lazier days of
summer, I thought taking on a lighter subject this week seemed appropriate for
the season.I have tried to take my
children walking from time and time and it just has not worked out quite like I
hoped.There were lots of complaints
about feet hurting and such after the first mile and tackling steep hills nearby
was unpleasant at best.However, this
summer, my only daughter is finally old enough to not only engage in pretty
deep and meaningful conversations but is enthusiastically joining me on long
walks.

A few nights ago, I found myself itching to get
outside before the sun went down and my daughter insisted on joining me.Sometimes I get impatient because her little
legs cannot match my grown up stride, yet the last few walks have allowed us to
settle into our own comfortable rhythm.My time with her is so emotionally fulfilling that the physical
differences have melted away.

We took off together and she filled me in on her
week at school (as I was out of town with one of my sons on a special vacation)
and everything else I missed while I was away.She covered the pretend games she played and the good, bad and ugly of
living with her three brothers.We were
so intent in our conversation that we actually missed the fact my parents drove
right past us.The only reason we became
aware of this fact is they turned around and came back to check on us.

We talked about our plans for the summer, which
season is the slowest at my office, and the difference between maiden names and
married names.It is really interesting
what things a five year old can come up with to discuss.Then she said something that piqued my interest
more than the anything else.“After we
finish tonight, we have walked 7 and one half miles,” she stated with a proud smile
on her face.Having only gone about a
mile and a half, I balked.

She expanded on her thought process a bit more.This was our third walk for the summer. The
others were three miles each (we started out on those a bit earlier than this
one.)Adding them all together she was spot
on with her calculation.I realized she
was, in fact, keeping track of our lifetime miles, though she called them “forever
miles.”I kind of like that phrase.I let her know of my loving approval on her
approach.

Then the real calculating began, literally and
figuratively.As we continued, she began
asking what her reward should be when we reach 100 miles.At first, I tried to pass off the reward as
being the time spent with her mom, but that went over like a pregnant
pole-vaulter.I suggested some things, a
few of which met with her approval.After
mulling this over a bit more, she wondered what we should do when we reach
1,000 miles together?My answer was something
to the effect that my reward would be “the book I get to write after 1,000
conversations.”She laughed and
suggested a vacation was a far better idea.

Regardless, it got me thinking about the fact that
whether or not we reach 100, 1,000, or even 10,000 miles together in our
lifetime, we will have time spent enjoying one another.Time is a gift we should all appreciate.I am well aware of the fact in 10 years, she
could recoil at the thought of taking a walk with dear old mom, but what if she
doesn’t?

I can only hope this is the beginning of something beautiful.At the very least, when she is fifteen, I can
remind her of the awesome idea that formed in her impressionable 5 year old mind.Imagine the conversations we will have had
after 1,000 miles with one another?It
is going to be a great summer.

Tuesday, June 13, 2017

In Louisville, Kentucky, Jewish
Hospital is a 342-bed facility similar in size and scope to Harrison Memorial
Hospital. It had knowledgeable physicians,
engaged staff, a bustling emergency room, and solid patient care ratings.Due to health care reforms, Jewish Hospital, St. Mary’s
Healthcare, and St. Josephs Healthcare (JHSMH)merged into one
organization, KentuckyOne
Health (KOH).To expand services
further, a joint
operating agreement between the University
of Louisville Hospital, a
private Cancer Center, and KOH was inked in 2013.University leaders supported this arrangement
because the parent company of KOH agreed to invest over
$500 million in the U of L facility.

Unfortunately, due
to unpredicted financial woes in 2014, KOH laid off 500
employees and left 200 open positions unfilled to yield $218 million in
savings.Many physicians were concerned
that “virtually all of the experienced nurses” were preferentially terminated.KOH contemplated closing one of their
hospitals, ultimately shuttering an emergency room instead.Despite these measures, KOH registered an operating
loss of $69 million.

An executive team was assembled to focus on revenue growth
and expense reduction.Vacant land was purchased nearby for “a new facility to meet the evolving needs of
the community.”Does this story sound
familiar? It should.The parent company
of KOH is Catholic Health Initiatives (CHI), the same organization that entered
our community a few years ago.

Greg Postel, MD, U
of L’s Vice President, warned KOH CEO Ruth Brinkley by letter “the number and quality of nursing staff has severely
declined” since affiliation.He alleged
these deficiencies damaged the U of L Hospital reputation and physicians were leaving due to “unsafe working conditions”
for staff.He accused CHI of breaching
the fiduciary obligations in the operating agreement, being $46 million in
arrears.

A complaint filed by the Vice-chair of Surgery, Dr. J.
David Richardson asserted a decline in morale and inadequate staffing was
compromising patient safety.“Patients
are being held in the ER until enough nurses are available,” he wrote. In an interview with the Courier-Journal, Dr.
Richardson thought the best resolution would be to “unwind” the joint operating
agreement.“They [KOH] are destroying
the hospital,” Richardson said.The following month, a state inspection confirmed nursing deficiencies had undeniably endangered patients.

In December 2016,
KOH and U of L Hospital terminated their agreement, releasing management of the U of L
Hospital and the cancer center effective July 1.CHI anticipates $272 million in losses from this dissolution.

Last fall, CHI began
merger talks with Dignity Health, a company facing financial difficulties of
its own with an operating loss in 2016 of $63 million across 39 hospitals.The
same year, CHI operating losses were almost $500 million amongst 103 hospitals.Both organizations already carry higher than
average debt loads, though with complementary markets, merging might be
advantageous.

Interested in
affiliation, CHI implemented a “turnaround plan,” to bolster their negotiating
position.However, 2 of CHI’s 11
“multi-hospital hubs,”the Louisville and Houston markets, are failing, necessitating relief from profitable markets like Ohio
and the Pacific Northwest group.KOH eliminated 250 non-clinical positions in the interest of fiscal
health last month.

The most alarming actions by KentuckyOne Health is the termination of 25 professional service agreements of their employed physicians
without justification.These are the
very same physicians who sold their private practices to KOH just 5 years ago.Dr. Richard Holt, a spine surgeon, was
affiliated with Jewish Hospital while practicing independently.He sold his practice to relieve the
overwhelming administrative burden and was satisfied working at the
hospital-based clinic, meeting productivity goals.Surprised
by sudden dismissal, his last day is July 31.Sadly, he will retire because at 69, he is no longer willing or able to
launch a private practice from scratch.

After five
years under the management of CHI, Jewish Hospital is being placed on the
auction block, to “slim down” operations. After divesting of almost every hospital
acquired over the last 5 years, they will concentrate on “opportunities for
growth” elsewhere.KentuckyOne Health may
be the red-headed stepchild, though we should not forget Jewish Hospital was a
thriving community hospital before their ill-fated merger.

The Pacific
Northwest hospital group may be considered the “golden child” for now, but what
happens if profit margins decline and further cutting costs is not feasible?
The Jewish Hospital merger experience should serve as a cautionary tale for Kitsap
County.Will our beloved community hospital be sold off
five years from now or can we escape the same fate by devising a viable
alternative for healthcare in our community?

Tuesday, June 6, 2017

A recent Medical
Economics article
asked “Is the DPC model at risk of failing?” The piece focuses on two large DPC-like organizations,
Qliance Medical Management of Seattle, Washington and Turntable Health of Las
Vegas, NV, working in partnership with Iora Health, which recently closed their
doors.Qliance and Turntable were not actually
DPC practices by strict definition; they were innovative large business
operations providing healthcare services to patients and excluding third party
payers.Their idea was commendable, but
their closure indicates little cause for concern in regard to the growing
Direct Primary Care movement.

Robert
Berenson, MD, who admits to not being a fan of the DPC model, said “Qliance has
been the poster child for DPC… If that one can’t make it… it suggests the
business model (of DPC) is flawed.”He is correct about one thing; the “business”
model of medicine is certainly flawed.What
he does not realize is DPC is not a “business” model; it is a “care”
model.Whether accepting insurance or DPC in
structure, we already know solo and two-physician practices deliver the best care
and have been doing so for the past 100 years.These intimate clinics know their customers better than anyone else in
the industry, and can devote the time necessary to their clientele; these
micro-practices should be known as the small giants of healthcare.

Strictly
defined, Direct Primary Care is where a patient and physician enter into a
contract to provide unlimited primary care services for an affordable monthly
fee (less than $100/month.) 80% of
healthcare needs can be met in a DPC practice. The typical DPC practice has 1
or 2 physicians, 600 patients maximum per physician, and on average each
physician sees 10 patients per day.Employees are minimal, usually including a receptionist and/or medical
assistant.Only minimal office space is
required to run such a lean operation, so overhead remains low.Supplies, medication, and equipment are
purchased on an as needed basis and used only when necessary.

Qliance,
founded in 2007 by Dr. Garrison Bliss and Dr. Erika Bliss, charged $64/month
for adult members and $44/month for children.They had 13,000 patients in total including primary care and emergency
care services, more than 20 times the number of patients compared to a
traditional DPC clinic.They were trying
to use a model embraced by the small giants yet contort it into something
entirely different simultaneously.After
10 years, the experiment failed.

Iora
Health, vying to become the “Starbucks” of
healthcare, was in partnership with Turntable Health utilizing a “team based” concept.Each “team” included a physician, nurse, and
a health coach.This model contracted
with individuals, but also employers and unions already paying for healthcare by
offering improved access to primary care services and pocketing a portion of
the savings that materialized.In this
model, physicians usually had 1000 patients and each health coach with a few
hundred.Turntable charged $80/month for
adults and $60/month for children to have access to their vision of a “wellness
ecosystem”, which included yoga, meditation, and cooking classes.

An article
in the New York Times quoted Duncan Reece, the VP of Business at Iora Health,
“We wanted to do something radically different and show this isn’t your
grandfathers’ doctor’s office.” Can
someone please tell me what was wrong with that model? It was a quintessential small giant of the
business world.My grandfather was an
outstanding general practice physician with a small office and one nurse on
staff.He made house calls.He did appendectomies, tonsillectomies,
C-sections, vasectomies, and met most of his patients’ basic primary health
care needs for 40 years.Why do we need
something radically different?

The bottom
line is healthcare requires two people – one physician and one patient.While it is a nice idea, we do not need yoga,
massage, or smoothie bars in our clinics to improve patient outcomes.Adequate medical knowledge and time for
meaningful conversations is essential; something the small giants of healthcare
are experienced in providing.The vision
of a “wellness ecosystem” should probably go the way of the “patient-centered
medical home,” as there is little cost savings or difference in outcomes
compared to the traditional fee-for-service system.

So what
qualities make the best practices? According to a study conducted by The
Peterson Center on Healthcare at Stanford, the very
bestprimary care practices have
either one location or a small handful of them.Stanford compiled a list of 10 distinguishing features of these top
practices and many are commensurate with being a “small giant” of the business
world.My favorite characteristic on the
list is to invest in people, not space or equipment.By lowering overhead, physicians are not relying
on patient volume to generate adequate income.These practices are consciously choosing to stay small by renting minimal
space and investing in added services only when believing them to be more cost-effective.

The
government and insurance companies cannot fix healthcare.It is up to physicians and patients– one
micro-practice or DPC clinic at a time.Dr.
Kimberly Legg Corba, owner of Green Hills Direct Family
Care, said “The DPC model is growing and practices are converting all the
time.Some are opening by transitioning
an established practice, some are physicians starting clinics fresh out of
residency from scratch, and others are leaving employed positions to return to practicing
medicine in a way they love.”

While my
practice is not DPC, it is a small, old-fashioned clinic serving families for as
long as three generations.Our records
are still on paper, a real human being answers the phone when it rings, and for
occasional emergencies, patients stop by my house for a “reverse house call.”My belief in the DPC model is steadfast
because any “care” model placing control directly into the hands of physicians
and their patients is worth fighting to preserve and protect.The more small giants able to thrive in the constantly
evolving healthcare landscape, the greater chance physicians have of inciting a
large scale revolution to benefit patients everywhere.

Since the
Affordable Care Act legislation went into effect, mergers and consolidations
have increased by 70%, at the expense of care becoming less personalized and
increasingly fragmented.These large
institutions are profit centers for CEO’s and business executives who have very
little knowledge of what goes on between a physician and a patient.They need the independent practice model to
fail so patient choice is no longer an option.

The small
giants, micro-practices and DPC clinics, will continue to prosper and grow
because a “care” model devoted to preservation of the physician-patient
relationship cannot be defeated. Physicians
must stop being afraid to take that leap of faith, leave employment, and go
back to doing what we love most, caring for our patients and improving their
lives.Physicians should be standing at the bedside,
not in front of computer workstations.Direct
Primary Care is a model for which we should all be rooting; it is transforming
the physician-patient relationship and restoring the practice of medicine to
its noble roots, allowing for the art, the science, and the wholly fulfilled
physician.

My advice
for patients everywhere:Whenever
possible, find an independent practice, whether a solo doctor or direct primary
care clinic, and patronize that physician.Your care will be more personalized, cost less in the long run, and your
health will be better for the investment you made in yourself.